Richard Lamb, M.D.,
Professor of Psychiatry, University of Southern California Keck School of Medicine, and Board Member, Treatment Advocacy Center

James Pavle Executive Director, Treatment Advocacy Center

May 2010

I. Executive Summary

(a) Using 2004–2005 data not previously published, we found that in the United States there are now more than three times more seriously mentally ill persons in jails and prisons than in hospitals. Looked at by individual states, in North Dakota there are approximately an equal number of mentally ill persons in jails and prisons compared to hospitals. By contrast, Arizona and Nevada have almost ten times more mentally ill persons in jails and prisons than in hospitals. It is thus fact, not hyperbole, that America’s jails and prisons have become our new mental hospitals.

(b) Recent studies suggest that at least 16 percent of inmates in jails and prisons have a serious mental illness. In 1983 a similar study reported that the percentage was 6.4 percent. Thus, in less than three decades, the percentage of seriously mentally ill prisoners has almost tripled.

(c) These findings are consistent with studies reporting that 40 percent of individuals with serious mental illnesses have been in jail or prison at some time in their lives.

(d) It is now extremely difficult to find a bed for a seriously mentally ill person who needs to be hospitalized. In 1955 there was one psychiatric bed for every 300 Americans. In 2005 there was one psychiatric bed for every 3,000 Americans. Even worse, the majority of the existing beds were filled with court-ordered (forensic) cases and thus not really available.

(e) In historical perspective, we have returned to the early nineteenth century, when mentally ill persons filled our jails and prisons. At that time, a reform movement, sparked by Dorothea Dix, led to a more humane treatment of mentally ill persons. For over a hundred years, mentally ill individuals were treated in hospitals. We have now returned to the conditions of the 1840s by putting large numbers of mentally ill persons back into jails and prisons.

(f) Any state can solve this problem if it has the political will by using assisted outpatient treatment and mental health courts and by holding mental health officials responsible for outcomes. The federal government can solve this problem by conducting surveys to compare the states; attaching the existing federal block grants to better results; and fixing the federal funding system by abolishing the “institutions for mental diseases” (IMD) Medicaid restriction.

II. Introduction

In the early years of the last century, the public was shocked to find that most mentally ill persons were being housed in local jails and prisons. Such conditions were regarded as inhumane, and a reform movement, led by Dorothea Dix, began. This movement led to the building of state mental hospitals and the belief that mentally ill persons deserved to be treated, not punished. The Appendix details this period, which continued until the 1950s, when deinstitutionalization began.

Deinstitutionalization, the emptying of state mental hospitals, has been one of the most well-meaning but poorly planned social changes ever carried out in the United States. It was a product of the overcrowding and deterioration of hospitals; new medications that significantly improved the symptoms of about half of patients; and a failure to understand that many of the sickest patients were not able to make informed decisions about their own need for medication. Deinstitutionalization drew enthusiastic support from fiscal conservatives interested primarily in saving funds by shutting state hospitals, as well as from civil rights advocates who believed that mental patients needed to be “liberated,” as in Ken Kesey’s One Flew over the Cuckoo’s Nest. This merging of the political right and left has made for strange—indeed, bizarre—bedfellows but has been a political juggernaut, ensuring that deinstitutionalization will continue to take place, as it does even today, despite clear evidence that for many patients it has been a disaster.1

California was in the vanguard of deinstitutionalization, as it has also been in the vanguard of experiencing its untoward consequences. Ronald Reagan, as governor of California, is often blamed for the failures of this policy, but such blame is not warranted. The emptying of the state’s mental hospitals began in the mid-1950s under Republican governor Goodwin Knight and continued in the 1960s under Democratic governor Edmund “Pat” Brown. When Reagan took office as governor, the hospitals had already been half-emptied. Reagan distinguished himself, however, by vowing to close the hospitals completely.

By the early 1970s, it was becoming evident that the emptying of the state mental hospitals had resulted in a marked increase in the number of mentally ill individuals in jails and prisons. In 1972 Marc Abramson, a psychiatrist in San Mateo County, published a study reporting a 36 percent increase in mentally ill prisoners in the county jail and a 100 percent increase in mentally ill individuals judged to be incompetent to stand trial. He also quoted a state prison psychiatrist who said: “We are literally drowning in patients. . . . Many more men are being sent to prison who have serious mental problems.”2 In 1973 hearings were held by the California State Senate to discuss this problem.

The San Joaquin County sheriff testified that “a good deal of mental illness is now being interpreted as criminality.” In Santa Clara County, the problem of mentally ill inmates had become “probably ten times larger” compared to the previous decade. However, when the lawmakers asked Dr. James Stubblebine, the director of the California Department of Mental Health, about the problem, he replied that “specific information is not available which would indicate that more discharged patients are going into the jails.” This was untrue; at the time Stubblebine testified, he had in his possession two studies, and soon would have a third, contradicting his reply.3 Stubblebine was an avid enthusiast of emptying the hospitals.

By the l980s observations and studies in many states indicated that an increasing number of the discharged mental patients were ending up in jails and prisons. In California in 1980 Gary Whitmer, a San Francisco social worker, published a study of “500 defendants in need of psychiatric treatment” and concluded that emptying the hospitals has “forced a large number of these deinstitutionalized patients into the criminal justice system.”4 In 1982 and 1983 Dr. Richard Lamb and his colleagues published two rigorous studies of mentally ill inmates in the Los Angeles County Jail and cited multiple other studies indicating that the problem was getting worse.5

(a) Studies done between 1980 and 1995

As reports of mentally ill persons in jails and prisons accumulated, additional studies were undertaken. Among these was a 1983–1984 study carried out by Dr. Linda Teplin in Chicago’s Cook County Jail. In a methodologically careful assessment of 728 jail admissions, Teplin reported that 6.4 percent of the prisoners had a serious mental illness (schizophrenia, bipolar disorder, or major depression) at the time of admission.6 This number was slightly higher than previous jail studies done in Denver (5 percent of inmates were said to have a “functional psychosis”)7 and San Diego (5 percent of inmates were said to be seriously mentally ill).8

In 1992 a jail survey was sent to each of the 3,353 jails in the United States. Jail personnel were asked to assess what percentage of their inmates were seriously mentally ill, defined as including schizophrenia, bipolar disorder, “and related conditions,” and the questionnaire included representative vignettes. A total of 1,391 usable responses were returned. The average number of seriously mentally ill inmates was 7.2 percent, with a range from 2 percent (jails in Wyoming) to 11 percent (jails in Connecticut, Colorado, and Hawaii).9

(b) Studies done since 1995

During the 1980s and early 1990s, the pace of deinstitutionalization accelerated as states realized they could save funds by closing hospital beds. In 1955 there had been 558,239 patients in the state mental hospitals; by the end of 1994, this figure had decreased to 71,619, meaning that 87 percent of the hospital beds had been closed. The fate of the discharged patients was foregone and obvious to anyone who cared to look. For example, in a study of 65 patients discharged from an Ohio state hospital, 33 of them had become homeless within six months of discharge and 21 of them had been arrested and jailed. The authors noted: “Psychotropic medications had been prescribed upon their discharge from the state hospital, but the respondents failed to take their medication and instead chose to self-medicate with alcohol and street drugs.”10

Thus, it is not surprising that studies of mentally ill individuals in jails and prisons done since the late 1990s have reported higher numbers than earlier studies had. A widely publicized study done by the U.S. Department of Justice in 1998 reported that 16.3 percent of inmates in jails and 16.2 percent in state prisons were “estimated to be mentally ill,” based on the self-report of symptoms or of having been admitted to a psychiatric hospital.11 The mentally ill individuals in prisons were also said to be more likely than other prisoners to have been convicted of violent crimes, including homicides, and to spend an average of 15 months longer in prison than other inmates.

In 2000 the American Psychiatric Association estimated that about 20 percent of prisoners were seriously mentally ill, with 5 percent actively psychotic at any given time.12

In 2002 the National Commission on Correctional Health Care issued a report to Congress in which it estimated that 17.5 percent of inmates in state prisons had schizophrenia, bipolar disorder, or major depression.13 In 2003 Human Rights Watch, based on interviews and visits to state and federal prisons, estimated that approximately 20 percent of the prisoners were seriously mentally ill.14 A 2006 Department of Justice survey, based on a selected sampling of inmates, reported that 24 percent of jail inmates and 15 percent of state prison inmates “reported at least one symptom of a psychotic disorder.”15 Thus, these studies all concluded that between 15 and 20 percent of jail and prison inmates had a serious mental illness.

The most recent, and methodologically most impressive, survey of mental illness among jail inmates was published in 2009. A total of 822 inmates in five jails (three in New York and two in Maryland) were assessed using a structured diagnostic interview to determine the existence of serious mental illness during the previous month. Serious mental illness was defined as including schizophrenia, schizophrenia spectrum disorder, schizoaffective disorder, bipolar disorder, brief psychotic disorder, delusional disorder, and psychotic disorder not otherwise specified. A total of 16.6 percent of the prisoners met criteria for one of these diagnoses in the previous month, with the rate among women (31.0 percent) being much higher than that among men (14.5 percent).16 This finding is consistent with higher rates of mental illness among women reported in other jail and prison surveys.

(c) Recent state reports

The higher rates of mental illness reported in the more recent jail and prison studies are supported by anecdotal reports from individual states. Examples of such anecdotal reports include:

Alabama: In 2007 state mental health commissioner John Houston said that the percentage of state inmates thought to be mentally ill had risen from 5 percent in 1971 to 20 percent in 2007. “We are more or less criminalizing mental illness,” he said. “Jail becomes a default mental-health facility because there are no resources to provide care.”17

California: In 2001 San Francisco jail officials said that the number of prisoners requiring mental health treatment had increased 77 percent in the past 10 years. In 2005 in Los Angeles, Sheriff Lee Baca said: “I run the biggest mental hospital in the country.”18 5 Colorado: At the 2007 conference of the County Sheriffs of Colorado, “it was a consensus among those who attended the conference that coping with the challenges posed by housing mentally ill inmates is the top problem facing sheriff’s offices statewide.” Pueblo County Sheriff Kirk Taylor said: “By default, we’ve become the mental health agencies of the individual counties.”19

Florida: In the Broward County Jail in 2007, 23 percent of the prisoners were taking psychotropic medication. Polk County Sheriff Grady Judd said: “Our jails and prisons collectively are the biggest mental-health facilities in the state. . . . Jails have become asylums for thousands of inmates with mental illnesses whose problems and needs far exceed what jails can provide.”20

Georgia: Between 1991 and 2001, the number of inmates with serious mental illnesses in Georgia’s prisons more than quadrupled. In 2006, 16.5 percent of the prison inmates “were receiving mental health services.” According to Dr. Dana Tatum, supervisor of mental health care in the Gwinnett County Detention Center, the number of mentally ill prisoners in the jail increased dramatically following the closure of the nearby state psychiatric facility in the late 1990s. “The schizophrenic and chronically mental [patient] population just exploded and we found ourselves being the hospital,” Tatum said.21

Kansas: In 2009 Undersheriff Michael Stover of the Sedgwick County Jail said that “nearly a third of those in jail take some kind of medication for a mental illness.” “We’re not trying to get into the business of running a state hospital,” Stover said. “But whether they’re a hardened criminal with an underlying illness or commit crimes because of their mental health, at some point they end up in local jails. You can’t manage them like you can the general jail population.”22

Maryland: In 2005 in Montgomery County, “between 17 and 20 percent” of prisoners in the county’s two jails “have a documented mental illness,” according to Arthur Wallenstein, director of the County Department of Corrections and Rehabilitation.23

Michigan: In 2003 it was reported that a study of “jails in Wayne, Kent and Clinton counties found that 51 percent of inmates suffered from mental illness, not including substance abuse. The most common illnesses were major depression, bipolar disorder, and schizophrenia and psychotic disorders.” A 2008 survey of state prisons reported that “20 percent of males and 25 percent of females have severe psychiatric symptoms.”24

Minnesota: According to a 2003 report, in Dakota County “about 30 percent of the [jail] population is taking anti-psychotic drugs.” In Hennepin County “six out of the 10 medications given to inmates are for treatment of a mental illness.”25 Missouri: In 2007 it was reported that 19.7 percent of inmates in the five state prisons “suffered from a mental illness.” In Boone County, Warren Brewer of the Sheriff’s Office estimated the number of mentally ill inmates to be “at least 30 percent.”26

New York: In 2002 the Sheriffs Office in Onondaga County estimated that 20 percent of the inmates were “mentally ill”; in Monroe county the estimate was 30 percent. In Niagara County, Sheriff Thomas Beilein estimated that 25 percent of jail inmates “have some sort of mental problem.” Beilein added: “They’ve closed the mental hospitals and pushed those people into the jails. It’s appalling that they are here.”27

Ohio: The Corrections Center of Northeast Ohio reported in 2009 that 25 percent of its inmates were on psychotropic medications; the cost of the drugs accounted for half of the medical budget. In the Lucas County Jail, 23 of the 24 inmates in the psychiatric unit were repeat offenders. Valerie Sylvester, the jail’s director of medical services, attributed the problem to the closing of psychiatric hospitals. “Deinstitutionalization was the worst thing that could ever happen,” she said.28

Oklahoma: Between 1998 and 2005, the number of inmates in the state prisons “on psychiatric medications more than tripled.” In one prison, it was reported in 2006 that 40 percent of the inmates were on psychiatric medication.29

Oregon: In 2003 in the Umatilla County Jail, 39 percent of the inmates were taking psychotropic medications. Sheriff John Trumbo noted: “State hospital doesn’t have the resources to treat these patients any more so we have to keep them. Our staff receives some training in working with the mentally ill, because we have to address these needs.”30

Texas: In 2008, 1,900 out of 11,000 inmates, or 17.3 percent, in the Harris County Jail were on psychotropic medications. Spending on mental health care in the jail had risen to $24 million per year, “and the combined cost of incarcerating and treating the mentally ill is $87 million annually.” A county official noted: “The jails have become the psychiatric hospitals of the United States.”31

Virginia: In 2008 a state mental health commission estimated that “15 percent of all inmates in states prisons and jails are seriously mentally ill.” Roanoke County Sheriff Gerald Holt said it was 25 to 30 percent in his jail. In Virginia Beach, Sheriff Paul Lanteigne “estimated that it typically takes at least six months to find an available bed for a deranged inmate at Eastern State Hospital or a nearby psychiatric center. Scores of people are sitting in his jail today, long after they would normally have been released on minor charges, because they are too sick to be freed.”32

In summary, national surveys and individual state reports both suggest that at least 15–20 percent of jail and prison inmates are seriously mentally ill. We have thus effectively returned to conditions that last existed in the United States in the 1840s (Figure 1).

III. Methodology of the Present Study

Given the evidence for the decreasing availability of psychiatric beds for individuals with serious mental illnesses and evidence for an increasing number of such individuals being incarcerated in local jails and state prisons, we undertook a study to examine this problem in each state. The question we asked was: What are the odds of a person with a serious mental illness being in a jail or prison compared to a psychiatric hospital?

Data on prisoners were obtained from the Bureau of Justice Statistics’ “Prison and Jail Inmates at Midyear 2005,” a survey based on data obtained for June 30, 2005.33 The states of Connecticut, Vermont, Rhode Island, Delaware, and Hawaii each have a combined jail and prison system. The numbers in Table 1 are the combined totals for all jails and state prisons in that state; federal prisons were not included. For this study the percentage of jail and prison inmates assumed to be seriously mentally ill was 16 percent. This assumption was based on the 2009 study by Steadman et al. of five jails in New York and Maryland, discussed in the previous section, in which it was reported that 16.5 percent of inmates had a serious mental illness, narrowly defined.34

Based on the data available, we believe an assumption of 16 percent is reasonable, if perhaps conservative. The main limitation of this statistic is that it has to be used for every state, when in fact it seems likely that some states are doing a better job than others in treating mentally ill individuals in the community so that they do not end up in jail or prison. However, data on individual state differences are not available; one of the recommendations of this study is that such data be collected as part of the five-year census of jails and prisons carried out by the Department of Justice. There are also known to be intra-state differences in community psychiatric care from county to county. Thus, some states that rank poorly in this survey may have good mental illness treatment programs in some counties.

Data on the number of inpatients in public psychiatric hospitals, private psychiatric hospitals, and the psychiatric units of general hospitals were obtained from the 2004 Inventory of Mental Health Organizations (IMHO), carried out by the Substance Abuse and Mental Health Services Administration (SAMHSA) under the U.S. Department of Health and Human Services.35 The data from the 2004 survey have not been previously published and are considered to be provisional. The number of inpatients was obtained for the first day of the hospitals’ reporting year, in most cases January 1 or July 1. Given the shortage of psychiatric beds in the United States, most patients who are admitted to hospitals are seriously mentally ill, although a minority of patients in private hospitals and the psychiatric units of general hospitals are not, e.g., may have a diagnosis of substance abuse only. The inclusion of all beds, both public and private, in the present survey makes the availability of psychiatric beds appear better for individuals with serious mental illnesses than it actually is.

In addition, the number of beds in this survey includes all forensic psychiatric beds, which are occupied by seriously mentally ill individuals who have been court-ordered to the hospitals. These include individuals who were found incompetent to stand trial, found not guilty by reason of insanity, sexually violent predators, etc. In California, for example, these individuals occupy 90 percent of the beds in the remaining state psychiatric hospitals.36 Such beds are essentially tied up with court-ordered, long-term patients and thus not really available for new admissions. By including these beds in the present survey, the survey further understates the seriousness of the problem of lack of psychiatric beds.

IV. Results of the Study

In 2004 in the United States, there were 100,439 psychiatric beds available in public and private psychiatric hospitals and in the psychiatric units of general hospitals. Since the population of the country was just over 300 million, that means that there was approximately one psychiatric bed available for every 3,000 people. This contrasts to the situation in the United States in 1955, when there was one public psychiatric bed available for every 300 people. Thus, even not including private psychiatric hospital beds or the beds on psychiatric units of general hospitals in 1955, an individual with a serious mental illness was 10 times more likely to find a psychiatric bed for treatment in 1955 than in 2004.

It is also useful to compare the present paucity of beds with the situation in the 1840s, when Dorothea Dix was decrying the practice of keeping mentally ill individuals in jails rather than in hospitals. As noted in the Appendix, in 1850 there was approximately one public psychiatric bed available for every 5,000 people. Currently, there is one bed available for every 3,000 people, including the beds in private psychiatric hospitals and on the psychiatric units of general hospitals. In fact, many beds in these latter units are not really available to individuals with serious mental illnesses, because most such individuals do not have insurance to cover the costs. Therefore, the situation faced by individuals with serious mental illnesses today is remarkably similar to individuals with serious mental illnesses in the 1840s—a shortage of psychiatric beds and an abundance of jail and prison cells. If Dorothea Dix came back today, she would feel right at home.

Regarding the odds of a seriously mentally ill individual being in jail or prison compared to a hospital, the odds for all 50 states was 3.2 to 1 that they would be in a jail or prison. This means that in 2004–2005, throughout the United States, there were more than three times more individuals with serious mental illnesses in jails and prisons than in hospitals.

The only state in which the odds were 1 to 1 was North Dakota; in that state, a mentally ill individual had an equal chance of being in a hospital compared to a jail or prison.

At the other extreme, in Nevada (9.8 to 1) there were almost 10 seriously mentally ill persons in jails and prisons for every one in a hospital. The situation in Arizona (9.3 to 1) was almost as bad as in Nevada, and Texas (7.8 to 1) was not far behind.

The other states in the bottom quarter of the rankings were South Carolina (5.1 to 1), Georgia (5.1 to 1), Florida (4.9 to 1), Louisiana (4.6 to 1), Idaho (4.6 to 1), Michigan (4.3 to 1), Colorado (4.1 to 1), Ohio (4.0 to 1), and Utah (4.0 to 1).

Is there any correlation between the states that are more likely to have mentally ill individuals in hospitals and states that are spending more money on their mental health treatment system? Expenditure data by state are available for fiscal 2002.37 Using a statistical test, there was a very strong correlation between those states that have more mentally ill persons in jails and prisons and those states that are spending less money on mental health services (Spearman’s rho = 0.4974; p < 0.001). Among the ten states most likely to be using hospitals, six were also among the ten states spending the most money per capita. Conversely, among the ten states mostly likely to have mentally ill individuals in jails and prisons, five were also among the states spending the least money per capita.

The exception in the latter group was Arizona, which ranked relatively high (14th) in spending but ranked next to last (49th) in likelihood of having mentally ill individuals in hospitals.

Another way to look at this problem is to ascertain what percentage of individuals with serious mental illnesses are put in jail.

A 1991 survey of 1,401 members of the National Alliance for the Mentally Ill (NAMI), an advocacy group for families of individuals with serious mental illnesses, reported that 40 percent of the mentally ill family members had been in jail at some point in their lives.38 Thus, it is fact, not hyperbole, that jails and prisons have become America’s mental hospitals. The country has reverted to a situation last seen in the early 19th century, when reformers such as Dorothea Dix inspired state legislatures to build psychiatric hospitals in which to place mentally ill individuals so that they would be treated more humanely.

V. Problems Associated with Having Seriously Mentally Ill Persons in Jails and Prisons

Jails and prisons are not created to be de facto mental hospitals. They are not structurally appropriate for patients, and the staffs are not recruited as psychiatric caretakers. Not surprisingly, there are many problems associated with placing large numbers of seriously mentally ill individuals into jails and prisons. Among these problems are the following:

(a) Mentally ill offenders are “frequent flyers”: Since the county and state corrections systems are separate from, and usually not coordinated with, the mental health system, most mentally ill persons leaving jails and prisons receive little, if any, psychiatric aftercare. Consequently the recidivism rate is thought to be higher than it is for other released prisoners.

In jails and prisons, repeat offenders are commonly referred to as “frequent flyers.” In the Los Angeles County Jail, 90 percent of mentally ill inmates are repeat offenders, with 31 percent having been incarcerated ten or more times. Houston’s Harris County Jail in 2008 included two mentally ill individuals who had been booked 30 times since 1999 and 45 times since 2001. Also included was a 34-year-old woman diagnosed with schizophrenia who had been charged with 12 felonies and 31 misdemeanors. At the Palm Beach County Jail, Jonathan Goode, diagnosed with schizoaffective disorder, was booked 49 times in 40 months between March 2006 and July 2009. The record for repeat offenders probably belongs to Gloria Rodgers, who after 259 arrests in Memphis, was finally committed to a state psychiatric hospital. Like many frequent flyers, Rodgers considered the Shelby County Jail to be her home. Similarly, Linda Kraige, diagnosed with bipolar disorder, has been in Virginia’s Roanoke County Jail so many times that, when asked to name her best friend, she named the deputy at the jail.39

(b) Mentally ill inmates cost more: Mentally ill inmates cost more than non–mentally ill inmates for a variety of reasons, including increased staffing needs. In Broward County, Florida, it costs $80 a day to house a regular inmate but $130 a day for an inmate with mental illness. In Texas prisons “the average prisoner costs the state about $22,000 a year,” but “prisoners with mental illness range from $30,000 to $50,000 a year.” Psychiatric medications are a significant part of the increased costs; in July of 2002 at Ohio’s Clark County Jail, prescription drugs costs for inmates exceeded the costs of feeding inmates. Psychiatric examinations are also expensive. In Palm Beach County, each time Jonathan Goode was arrested he was required to have a psychiatric exam, each costing $2,000, producing an expenditure of $98,000 over 40 months. Finally, there is the cost of an increasing number of lawsuits, such as the suit brought in New Jersey in 2006 by the family of a “65-year-old mentally ill stockbroker [who was] stomped to death in the Camden County Jail.”40

(c) Mentally ill inmates stay longer: In Florida’s Orange County Jail, the average stay for all inmates is 26 days; for mentally ill inmates, it is 51 days. In New York’s Riker’s Island Jail, the average stay for all inmates is 42 days; for mentally ill inmates, it is 215 days. The main reason mentally ill inmates stay longer is that many find it difficult to understand and follow jail and prison rules. In one study, jail inmates were twice as likely (19 percent versus 9 percent) to be charged with facility rule violations. In another study in the Washington State prisons, mentally ill inmates accounted for 41 percent of infractions even though they constituted only 19 percent of the prison population. Another reason mentally ill inmates stay longer is that they are often held for months awaiting the availability of a bed in a psychiatric hospital.41

(d) Mentally ill inmates are often major management problems: Because of their impaired thinking, many inmates with serious mental illnesses are major management problems. For example, in 2005 in Mississippi’s Hinds County Jail, one inmate was described as having “tore up a damn padded cell that’s indestructible, and he ate the cover of the damn padded cell. We took his clothes and gave him a paper suit to wear, and he ate that. When they fed him food in a styrofoam container, he ate that. We had his stomach pumped six times, and he’s been operated on twice.” In the Southern Ohio Correctional Center in 2004, a mentally ill inmate who had been sent to jail for stealing a bicycle was described as follows: “He was the type of individual who was very difficult to work with. [He’s] been very aggressive towards staff, including, I believe, by spitting on staff members and throwing body waste. And so there wasn’t a lot of empathy for him. . . . The tendency would be for somebody like that to just [say], ‘Let’s lock him away. . . . let’s just not have anything to do with him.” In Wisconsin a 2010 audit of three state prisons reported that “between 55 percent and 76 percent of inmates in segregation [isolation] are mentally ill.” 42

(e) Mentally ill inmates are more likely to commit suicide: Multiple studies have shown that approximately half of all inmate suicides are committed by inmates who are seriously mentally ill. A 2002 study in Washington State reported that “the prevalence of mental illness among inmates who attempted suicide was 77 percent, compared with 15 percent [among inmates] in the general jail population.” In California in 2002, the Los Angeles Times headlined: “Jail Suicides Reach Record Pace in State,” and added: “Some experts blame the recent surge on forcing more of the mentally ill behind bars.”43

(f) Mentally ill inmates are sometimes abused: Men and women who work as correctional officers in jails and prisons apply for the job expecting to work with criminals, not individuals with serious mental illnesses. Many of the correctional officers do not understand, and have little or no training in, how to work with mentally ill inmates.

Pete Earley, in his excellent book about mentally ill people in jails, described a conversation he had with correctional officers in Miami’s Dade County Jail: I was told the inmate had been punched several times in his kidney area and his arm had been twisted behind his back while, as one officer said, “he was given a talk-to about his lack of respect and manners.” . . . “You need to instill fear in these inmates or they won’t listen to you,” one explained. “Especially crazy inmates, ’cause if you don’t scare them, then they will hurt you.” . . . “We don’t have any way to control these inmates except with behavior modification, which is a nice way to say: putting our hands on them if they get out of line. I mean, how else can we keep them under control? You tell me?”44

VI. Possible Solutions

Emptying America’s mental hospitals without ensuring that the discharged patients received appropriate treatment in the community has been an egregious mistake. For the approximately half of discharged patients who have ended up homeless or in jails and prisons, it has been a personal tragedy. Although deinstitutionalization was well intentioned, the failure to provide for the treatment needs of the patients has turned this policy into one of the greatest social disasters of the 20th century. It is an ongoing disaster because states are continuing to close psychiatric hospital beds, with present administrators of state mental health programs seemingly oblivious to the problems they are causing.

The present mental health system appears to be bankrupt of ideas for fixing this disaster. In Florida, Dade and Broward Counties are designing “the first county jails ever to be built specifically for inmates with chronic and severe mental illness.”45 In Maine it has been proposed to close some jails and transform them “into short-term lockups or specialty facilities for people with mental illnesses.”46 In Montana a proposal has been made to open “a special prison for the mentally ill who are now housed in the regular prison.”47 In Pennsylvania “lawmakers are considering a novel idea to deal with prison overcrowding . . . [by] moving prisoners with mental illnesses into state mental hospitals.”48

In New York State, lawmakers essentially have done this. Marcy State Psychiatric Hospital was shut down many years ago and turned over to the State Department of Corrections to become the Marcy Correctional Facility. Then, in December 2009, it was announced that the Marcy Correctional Facility would open a 100-bed Residential Mental Health Unit for inmates with serious mental illness. Thus, seriously mentally ill individuals who were once treated in the psychiatric hospital may end up being treated in exactly the same building, except that now it is called a prison. Office of Mental Health Commissioner Michael Hogan lauded the special unit as “a collaborative and innovative approach that to our knowledge is the first of its kind anywhere.” And Governor David Paterson said: “This cutting-edge program represents government at its best.”49 Government at its best? In less than 200 years, we have taken mentally ill individuals who were in jails and prisons; transferred them to mental hospitals; then we closed down the mental hospitals, thereby forcing the mentally ill individuals back to jails and prisons. This seems like a classic case study on how not to execute public administration, a never-ending cycle of failed policies.

This is government at its worst.

If administrators at the state and federal level are looking for real solutions, they should consider the following possibilities:

(a) Use assisted outpatient treatment (AOT): We need to make sure that seriously mentally ill individuals being released from hospitals, jails, or prisons get the treatment they need to not relapse. A proven way to do this is to utilize assisted outpatient treatment (AOT), which requires selected seriously mentally ill persons to take medication under court order as a condition for living in the community. In two studies, AOT has been demonstrated to be very effective in reducing the arrest rate of mentally ill persons. In North Carolina a randomized study reported that patients “with a prior history of multiple hospitalizations combined with prior arrests and/or violent behavior” had a reduction in arrests from 45 percent to 12 percent in one year while participating in AOT.50 In New York the percentage of mentally ill individuals arrested decreased from 30 percent to 5 percent, and the percentage of those incarcerated decreased from 23 percent to 3 percent while on AOT.51 In both studies, AOT was also accompanied by a major reduction in alcohol and drug abuse. AOT has also been shown to dramatically decrease psychiatric rehospitalization as well as homelessness, risk of suicide, and episodes of violent behavior among individuals with serious mental illnesses.52, 53, 54, 55, 56, 57, 58

(b) Use mental health courts: We should expand the use of Mental Health Courts, which essentially give offenders a choice between following a treatment plan (including the taking of medication) or going to jail. Studies have shown that mental health courts are effective.59, 60 The court thus becomes the de facto treating authority, a task originally assigned to the failed psychiatric outpatient clinics and community mental health centers.

(c) Conduct unannounced surveys: The Department of Justice or Institute of Medicine should carry out an unannounced survey in each state approximately every five years, enumerating the number of seriously mentally ill prisoners in jails and prisons. Then tie the federal mental health block grant to the results by state, with states having the fewest mentally ill prisoners getting the most money.

(d) Shift the funds: States should require that for each additional state-funded psychiatric bed that is closed, the projected savings should be transferred from the budget of the Department of Mental Health to the Department of Corrections. States should also require that county departments of mental health pay the local corrections department for the treatment costs of all seriously mentally ill jail inmates.

(e) Fix the federal funding system: The present funding system for mental health services is a large part of the problem. Federal Medicaid is the single largest source of funds, especially the restriction for using Medicaid funds to support mentally ill individuals in “institutions for mental diseases” (IMDs). The present fiscal incentives encourage states to empty hospitals, even if the patients end up in jails or homeless; there are no fiscal incentives to follow up and make sure the patients receive care once they leave the hospitals. The federal government could take a major step toward fixing the system if they repealed the Medicaid IMD restriction.

(f) Reform the treatment laws: States should reform their mental health treatment laws so that treatment interventions can be made based on need for treatment standards rather than on dangerousness. Many times, it is this very dangerousness standard that necessitates law enforcement involvement. Mentally ill individuals should be able to access treatment before they become dangerous or commit a crime, not after. Finally, as Newsday noted: “We should not pine for the ‘good old days’ before deinstitutionalization. But we should ask ourselves how a good idea went so terribly wrong.”61

In the United States, the first public outcry against putting mentally ill individuals into jails and prisons occurred in the early years of the 19th century. Louis Dwight, a Congregationalist minister in Massachusetts, was shocked by what he saw when he began taking Bibles to prisoners in jails. In response to Dwight’s advocacy, in 1827 the state legislature appointed a committee to investigate; the committee recommended that confinement in jails of mentally ill persons be made illegal and that those in jails be transferred to hospitals. Shortly thereafter the legislature approved the erection of the State Lunatic Asylum at Worcester for 120 patients.62 Dorothea Dix, the most famous and successful psychiatric reformer in American history, picked up where Dwight left off. During 1841 and 1842, she visited every jail in Massachusetts and documented the mistreatment of mentally ill prisoners. The following year, she presented her findings to the state legislature: “Men of Massachusetts, I beg, I implore, I demand . . . Raise up the fallen; succor the desolate; restore the outcast; defend the helpless.”63 Dix extended her crusade to many other states and by 1847 had visited 300 county jails and 18 state prisons. Her efforts led to the building of many new state mental hospitals.

At the time Dix was advocating on behalf of mentally ill persons incarcerated in jails and prisons, there was approximately 1 public psychiatric bed available for every 5,000 people in the population (the 1850 census, the first reliable enumeration of mentally ill persons in the United States, counted 4,730 insane persons in the total population of 23,261,000). A century later, in 1955, prior to the beginning of deinstitutionalization of mental patients in the United States, there was approximately 1 public psychiatric hospital bed available for every 300 people in the population (559,000 patients in state and county mental hospitals in a total population of 165,000,000).64 During those 100 years, there were some changes in diagnostic nomenclature, but public psychiatric hospital beds were largely reserved for individuals with serious mental illnesses, specifically schizophrenia, schizoaffective disorder, bipolar disorder, and major depression.

The advocacy efforts of Dorothea Dix and her colleagues to move mentally ill persons from jails and prisons to mental hospitals were largely successful. The 1880 census of mentally ill persons, the most complete survey ever carried out in the United States, identified 40,942 “insane persons” in “hospitals and asylums for the insane.” It also reported finding only 397 “insane persons” in jails and prisons, constituting less than 1 percent (0.7 percent) of the jail and prison population.65 Other studies done between 1880 and 1960 also found comparatively low prevalence rates of mentally ill persons in jails and prisons. For example, a 1930 study of almost 10,000 arrestees reported that just 1.5 percent of them were psychotic at the time of arrest.66 Thus, for almost 100 years, the problem of mentally ill persons in jails and prisons appeared to have been solved. These individuals were treated as patients, not as criminals, and were sent to mental hospitals, although the hospitals had little treatment to offer them at that time.

In 1939 Lionel Penrose, a British psychiatrist and mathematician, published a paper on the relationship between the population of psychiatric hospitals and that of prisons. He postulated that the two populations were inversely correlated: as one decreases, the other increases.67 It has become known as the balloon theory—push in on one side and the other side bulges out. What Penrose did not know when he published his paper was that the United States was about to embark on a grand social experiment— deinstitutionalization—that would test his theory.

Acknowledgments

We are grateful to Laura Milazzo-Sayre and Joanne Atay at SAMHSA, who provided the 2004 psychiatric patient data. Paige Harrison and Margaret Noonan at the Bureau of Justice Statistics kindly guided us through the prisoner data. We also thank Dr. Faith Dickerson, who provided statistical assistance, and Judy Miller, who provided administrative assistance.

The information on Mental Illness Policy Org. is not legal advice or medical advice. Do not rely on it. Discuss with your lawyer or medical doctor. Mental Illness Policy Org was founded in February 2011 and in order to maintain independence does not accept any donations from companies in the health care industry or government. That makes us dependent on the generosity of people who care about these issues. If you can support our work, please send a donation to Mental Illness Policy Org., 50 East 129 St., Suite PH7, New York, NY 10035. Thank you. Contact office@mentalillnesspolicy.org Contact DJ Jaffe, founder http://mentalillnesspolicy.org.